<p> Form 000.653.F0129 Line Break Permit</p><p>Project Name Project No./Contract No. - </p><p>Project Location Requestor Name Date</p><p>Description of Work</p><p>Special Instructions</p><p>Personal Protective Equipment Check Check Other Protective Measures (PPE) Required Yes No Yes No</p><p>Air Pack – Approved Barricade - ______Radius (above/ below) Boots – Rubber Boots Blanks to be Installed Coveralls -Tyvek Block Valve Shut Film Badge Blower Gloves – Long Gloves Fire Extinguisher Gloves – Leather Gloves Grating, Floor Opening Covered Gloves – Rubber Gloves Lockout Plan Required Goggles Piping Support Installed/Needed</p><p>Hood – Acid Hood Planning (Line Break Planning Items Page 2 completed and distributed to all personnel0 Respirator – Full-Face Respirator involved) Respirator – Half-Face Respirator Pump Locked Out Shield – Face Shield Spark Proof Tiles Shield – Special Shielding Standby Person Suit – Acid Suit System Less Than 212 °F (100 °C).</p><p>Suit – Hot Suit System Vented Suit - Rain Valve Locked Out Other: Water Hose Other: Other: Other: Other: Other Other: Other: Other:</p><p>Copyright © 2009, P2S. All Rights Reserved. Page 1 of 2 Health, Safety, and Environmental Form Date: 01May2009 Form 000.653.F0129 Line Break Permit</p><p>Planning Items for Line Breaks</p><p>1. Depressurizing, Cleaning, and Venting Check </p><p>Nearest Safety Shower Location (if greater than 50 feet 2. [15.2 meters], water hose must be provided)</p><p>3. Nearest Eyewash Location </p><p>4. Cold Pak Location </p><p>5. Scott Air Pak Location </p><p>6. Fire Extinguisher Location </p><p>7. Fire Alarm Location </p><p>8. Stretcher Location </p><p>9. Planned Escape Route </p><p>Relaxing PPE Requirements Date Time</p><p>PPE reduced to items shown below:</p><p>Approval Name Signature Date Client Representative</p><p>P2S Supervisor</p><p>Person Making Break</p><p>Person Making Break</p><p>Line Break Permit Issuer</p><p>Note: This form is referenced in Practice 000.653.3320.</p><p>Copyright © 2009, P2S. All Rights Reserved. Page 2 of 2 Health, Safety, and Environmental Form Date: 01May2009</p>